Pneumonia in Kids: Antibiotic Guideline Adherence Rising

Diana Phillips

June 23, 2015

The use of a single, narrow-spectrum antibiotic such as ampicillin/penicillin is increasingly the first line of treatment for children hospitalized with community-acquired pneumonia (CAP), according to a recent study. Broader-spectrum agents such as third-generation cephalosporins have largely fallen out of favor since the 2011 release of the first national consensus management guidelines recommending the revised strategy.

Adherence to the guidelines has been most prevalent among hospitals that proactively disseminated the recommendations, the researchers write. The findings point to the efficacy of individual hospital-based initiatives for timely implementation of national guidelines, Derek J. Williams, MD, MPH, from Monroe Carell Jr Children's Hospital in Nashville, Tennessee, and colleagues report in an article published online June 22 in Pediatrics.

To assess the effect of the 2011 guidelines, which emphasize a single, narrow-spectrum antibiotic for vaccinated children hospitalized with uncomplicated CAP, the investigators looked at the prescribing practices at three children's hospitals as part of the Centers for Disease Control and Prevention's Etiology of Pneumonia in the Community (EPIC) study: a prospective, population-based active surveillance of CAP among children between January 1, 2010, and June 30, 2012.

Before the guideline release, broader-spectrum antibiotics were the more common treatment choice, despite the strength of evidence supporting narrow-spectrum antibiotics, including the identification of Streptococcus pneumoniae as the most common causative bacterial pathogen in pediatric CAP. Penicillin-resistant pneumococcal disease has decreased since the introduction of the conjugate vaccine, and high-dose penicillin has been proven effective for pneumococcal infections outside the central nervous system.

Of 2121 children hospitalized with CAP included in the analysis, 52.8% (interquartile range, 47.8 - 56.6) received third-generation cephalosporins during the preguideline period compared with 2.7% (interquartile range, 2.1 - 7.0) who received penicillin/ampicillin. In contrast, by 9 months after guideline release, "the proportion of children who received empirical treatment with third-generation cephalosporins progressively declined, whereas penicillin/ampicillin use increased," the authors write.

"By the end of the study period, and compared with the expected use estimated from the preguidelines trend, we noted an absolute decrease of −12.4% (95% confidence interval [CI], −19.8% to −5.1%) for third-generation cephalosporin use and an absolute increase of 11.3% (95% CI, 4.4% to 18.3%) for penicillin/ampicillin use."

Two of the three hospitals included in the study highlighted the prescribing guidelines during educational conferences, and the infectious disease division at one hospital endorsed the recommendation for penicillin/ampicillin use and disseminated it via email to all pediatric faculty.

"Although we could not assess the penetration of formal initiatives or characterize informal activities at each hospital, the 2 institutions that incorporated active, hospital-based educational efforts demonstrated the largest reductions in third-generation cephalosporin use along with the largest increases in penicillin/ampicillin use," the authors write. "At both hospitals, penicillin/ampicillin use was equivalent to third-generation cephalosporin use by the end of the study period. Dissemination efforts at these 2 hospitals were similar and included departmental educational activities shortly after release of the guidelines."

At the hospital without active educational efforts, the declines in prescribing of third-generation cephalosporins and increases in penicillin/ampicillin use were more modest and did not reach statistical significance. These findings emphasize the importance of active hospital-based efforts for rapid implementation of guideline recommendations, the authors explain.

Despite the overall high level of guideline adherence, there is room for improvement, the authors write. "[T]hird-generation cephalosporins were still prescribed for 44.8% of children by the end of the study period (although in some circumstances broader-spectrum therapy was appropriate, eg, critical illness)."

More studies are needed "to monitor the spread and long-term sustainability of these initial encouraging observations and to identify the most effective hospital-based strategies to facilitate rapid implementation of national guidelines," the authors conclude.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online June 22, 2015. Abstract


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